Young people who smoke tobacco through a water pipe – also known as a hookah, shisha, or goza – are more likely to use illicit drugs than their non-smoking contemporaries, according to a study of young Canadians. Most notably, hookah smokers were much more likely to smoke marijuana: 74% of water-pipe users reported marijuana use, compared with 35% of non-users.

A hookah or shisha comprises an upright device with a small platform where tobacco, often flavoured, is burned, a metal body, a base half-filled with water, and a tube with a mouthpiece for inhaling.

Smoking tobacco using water pipes is an old Arabic tradition that is becoming more popular in the Western world, with an estimated 40% of US college students and 38% of British university students having ever used a hookah.

The rise in popularity is thought to be linked to the perception that smoking tobacco through a water pipe is harmless. However, water pipe smoke may contain greater amounts of tar and heavy metals, such as lead, than cigarette smoke and has been linked to lung cancer, heart disease, and infectious diseases.

In this study, the authors posted questionnaires to 1,208 18-24 year olds who lived in the Montreal area of Canada, 878 (73%) of whom responded and 871 (72%) of whom were included in the analyses.

A total of 204 participants (23%) reported having smoked tobacco using a water pipe in the past year. Among these water-pipe users, 78% smoked water-pipes less than once per month, 19% smoked 1-3 times per month, and 3% smoked 1-6 times per week. None used a water pipe every day.

Individuals who had used a hookah were younger, more likely to be male and not living with their parents, and had a higher household income than those who hadn’t, leading the authors to suggest that “Water-pipe users may represent an advantaged group of young people with the leisure time, resources, and opportunity to use water-pipes.” So hookah smokers are nice middle class kids with too much time on their hands then?

Compared with people who hadn’t used a water pipe in the previous year, those who had were more likely to have also used cigarettes and other tobacco products like chewing tobacco or snus and to have used alcohol, including having up to five or more drinks on one occasion (i.e. to a binge drinking level). Interestingly, a third of water-pipe users had not smoked cigarettes in the past year, perhaps using a hookah as a perceived “healthier” alternative.

Water-pipe users were more likely to have used marijuana (74% vs 35%) or other illicit drugs like speed or cocaine (33% vs 11%) in the past year, suggesting perhaps that smoking tobacco through a water pipe may act as a “gateway” to using more harmful substances. Nevertheless, the authors point out that the design of their study means no cause and effect inferences can be drawn between using a hookah and illicit drug use.
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Dugas E et al. (2010) Water-Pipe Smoking Among North American Youths. Pediatrics DOI: 10.1542/peds.2009-2335